Part 2: Getting back to the basics of hygiene

Sept. 1, 2001
Have you ever wondered why instructors in a hygiene school taught you the way they did?

by Tammy L. Carullo, RDH, PC, PS

Have you ever wondered why instructors in a hygiene school taught you the way they did? Who decided on the curriculum and the importance of needing to know all of that information? They then demanded that you followed all of those procedures in clinic, when it clearly doesn't matter in the world of private practice. Or does it? Far too often, reality suggests that what should be done in a dental practice is rarely what is actually being done.

The truth of the matter is that the complacency rut that often occurs is more than just a bad habit. It can lead to substandard care for patients. The curriculum in hygiene schools across the country is in place for a reason — to teach the fundamentals of providing excellent, comprehensive dental care. However, when we start randomly omitting procedures due to reasons such as time restraints or laziness, we are doing a grave disservice to our patients.

Ask yourself, "Am I currently practicing at the same proficiency that I had upon graduation?" Are you keeping current through continuing education in order to provide patients with the best level of treatment? Getting back to the basics of hygiene is one of the most important tasks you can do to ensure your future in the profession, as well as the health of your patients. Whether you are a new graduate or someone who has been around the block, it is essential that you dust off textbooks and start refreshing your clinical memory.

What's more basic than charting?
Very few of us will ever forget the stack of paperwork that accompanied every patient while we were in hygiene school. At the time, we thought our instructors were simply being brutal, that this was the epitome of "busy work." The truth of the matter is that this mountain of forms and charts were, and still are, the cornerstone of providing effective and superlative treatment. Based on personal observations while conducting on-site training in dental practices, it amazes me to see the number of cases where an inadequate amount of information is collected and recorded. The assessment phase of treatment is minimal at best.

Periodontal charting, for example, needs to be accurate and thorough. Unfortunately,I encounter only a minority of practices that do a good enough job to provide all of the information necessary to make a complete assessment of the patient's status. What happened to providing baseline evaluations? We're talking about recording six-point probe readings on every tooth. Record also bleeding upon probing, gingival attachment, gingival appearance, recession, and mobility.

The problem that exists if this information is not gathered properly is an inadequate evaluation. You have nothing upon which to measure subsequent appointments. A great example comes from a periodontal practice that I consulted with recently. The practice clearly had not been providing enough assessment information, especially with reference to classifying bleeding upon probing. A patient would present at one appointment with bleeding, and a very common chart entry such as "Perio 1-4 mm with BOP" would be made. Unfortunately, this is not an adequate entry.

There are four major classifications of bleeding upon probing, based upon the requirements set forth by the American Academy of Periodontology.

  • Class I — A spot of blood at the probe site.
  • Class II — The spot of blood spreads along the gingivae.
  • Class III — The spot of blood spreads along the gingivae and up the proximal wall.
  • Class IV — Hemorrhagic response.

Clearly, you can see the difference between Class I and Class IV. Unfortunately, if you do not clearly record the data of a patient that presents with Class I at one appointment, how will you know if there has been a significant change in health at the following appointment?

In the particular practice in question, a patient presented with Class I at an initial appointment, but it was not recorded as Class I. During a later appointment, the patient was in a Class IV hemorrhagic response. This patient slipped through the cracks in the system. A referral was needed, but there was no clear-cut documentation of bleeding upon probing. If you do not subclassify bleeding, you could potentially make this same costly error.

You also need to issue each patient a periodontal-status report or periodontal classification. Remember the days of Class I - IV patients in clinic? Why don't we do that in private practice? It made so much sense back then, and it still makes sense today.

Unfortunately, we have gotten so far removed from what we did in school. We have allowed the pressures of the real world to impair our judgment of what is acceptable for omission and what is not. We truly need to get back to the basics of dental hygiene and provide our patients with the level of care they deserve. The "10 steps to patient care" below shows how to get started on the road back to the basics.

10 steps to patient care

1. Radiographs and data gathering — In order to conduct a thorough and complete assessment, diagnosis, and subsequent treatment, you need to first obtain the appropriate data. Radiographs are one of the most valuable tools when reaching these interpretations. Unfortunately, far too often, hygienists fall woefully behind on keeping current radiographs in patients' charts.

As a consultant, I overhear a great deal of the communication between clinician and patient. One frequent error is to portray potential treatment of any kind in the form of a question. For example, a clinician will ask, "Mrs. Young, it has been a while since we've taken X-rays on you. Would it be all right if we got those today?" The most frequent response is, "No, I'd rather wait." If you give your patients the option to say no, chances are they may take you up on your offer.

Always state treatment in a matter-of-fact tone. Unless I am mistaken, there isn't anyone out there who has suddenly acquired the ability to see beneath gingival or restorative structures or inbetween teeth. Radiographs are necessary. Without them, we cannot make the necessary assessment and, therefore, the treatment chain is broken.

This 10-step plan is done in sequential order for a reason. Above and beyond the X-ray issue lies the data collection with regards to medical and dental history. This information is paramount in providing a greater insight into any potential problem areas with this patient. Many medical conditions and medications have a direct bearing on the oral health of your patients. Realizing the need for acknowledgement is the first step to accomplishing your goals.

2. Assessment of data — Baseline evaluation is the first thing that comes to my mind. Using your radiographs and your patient data you've collected, you can now begin gathering an accurate baseline evaluation, including gingival appearance, probings, attachment levels, intraoral cancer screening, extraoral examination, tooth mobility, furcation involvement, periodontal classification, medical and/or family history concerns, etc.

The establishment of an accurate baseline often is the most overlooked aspect of periodontal treatment, yet one of the most important. Keep this in mind: We refer continually to perio with regards to hygiene and dental care because, without a solid periodontal foundation upon which to build, all cosmetic and restorative structures will inevitably collapse.

The assessment step is crucial because you are providing the necessary information to make diagnoses and, subsequently, plan the direction of treatments. This is the essential map on the journey to the patient's acceptance of care.

3. Diagnosis and interpretation — While the hygienist's hands may be legally tied when it comes to diagnosis, your opinion is pivotal in interpreting and classifying patients. The unprecedented amount of time a dental hygienist spends with a patient (in comparison to the dentist) represents a unique opportunity. The hygienist has a clear-cut advantage in the interpretation department. Besides collecting data, as well as assessing and interpreting it, the hygienist can provide insight into how the patient responds and/or feels about his or her oral health and every point of care up to the current date. This makes it much easier to transition into a positive case acceptance.4. Patient education — Not just OHI! Long gone are the days when simply teaching a patient how to brush and floss was sufficient. Patients are now well versed in the dental scheme of things. They want — as well as need to know — all of the facts before making an informed decision.

Giving patients ample opportunity to ask any and all questions is the cornerstone of patient education. A wide scope of new and innovative tools helps your patients reach an optimal level of home care. But beware of one thing. If you do not have firsthand knowledge in how to use an oral hygiene tool, such as a home irrigator, do not recommend it to your patients.

The one thing the keep at the forefront of your mind is to use everything at your disposal, ranging from verbal communication to visual demonstration.

5. Presentation of findings — Once you have presented your findings and interpretation to the patient, it is very necessary to bring the dentist up to speed. The doctor needs to know exactly what you have discussed with the patient.

I must state that before conducting any of these steps, you must first have established a good working relationship conducive to this type of cotherapist environment. The environment is one where the dentist allows this scope of involvement, and where a practice is willing to capitalize on your expertise to its fullest capacity.

6. Practice acceptance — I often hear dentists listing case acceptance as their number one concern. Too often, they overlook one very simple, yet crucial, component to accomplishing this goal — practice acceptance. If, during the first visit or two, a new patient is presented with a huge amount of dental work that "needs" to be done, you have just cut your chances of acceptance of that work by 50 percent.

But the majority of practices still have not learned from this very crucial mistake. Many still are under the "high sell" spell. If you pressure your patients, you will lose your patients. Instead, concentrate on creating an environment conducive to an open and honest relationship, one that will lend itself to questions and low-stress treatment.

If patients are expected buy the Golden Gate bridge, they will seek treatment elsewhere. However, if the staff first establishes practice acceptance before presenting the mother lode of all cases, the patient just may come to you with an offer to buy that landmark outright.

7. Treatment-planning strategy — When you have established practice acceptance, all of the data is in place, and the patient informed of home-care options, you begin the task of treatment-planning. Involve your patients, as they have been involved since the beginning of their time on this earth. To keep them in the dark now would only result in a lack of case acceptance.

Talk to your patients. Patient education is not a "once and done" thing, but an ongoing essential throughout the entire treatment process.

While treatment-planning, put everything in writing. Remember, you want your patients to make an informed decision regarding their care. How can they accomplish this goal without being informed? Putting timelines, estimated costs, and suggested treatment in writing will provide the patient with information for making an appropriate decision. Many patients only retain approximately 32 percent of anything stated to them verbally. So, by putting it in writing, they then can review the information once they are at home, discuss it with any pertinent family members, and come up with questions or concerns.

One word of caution — please keep it simple! A treatment plan that is too complex will scare your patient away from the ultimate goal of case acceptance. Inform, but do so selectively for the best possible outcome.

8. Case acceptance and scheduling — You've done it! Your patient has accepted the treatment recommendations you have prescribed! Way to go! Now you have the potentially endless task of how to go about scheduling the patient. If the case is that of an operative nature, the schedule is generally forgiving and accommodating.

However, if the recommended treatment is periodontal soft-tissue management (quadrant scaling and root-planing), the task to find openings in a hygiene schedule that books six months out may be a daunting task. One very simple solution is hygiene "scheduling blocks." These time slots are blocked to accommodate patients on a last-minute basis. The worst thing a practice can do at this stage of the game — once a patient agrees to the treatment — is to tell the patient you can do it, but not for three to four months! This will most definitely squelch patient acceptance.

9. Implementation — You are ready to begin the treatment phase of the process. It is paramount that your clinical skills be up-to-date and that you have avoided that infamous "complacency rut."

Know your stuff. The information needs to be state-of-the-art, the instrumentation cutting-edge, and your approach subtle, yet thorough. Make certain that your patients leaves knowing that you have provided the best possible level of care for them and that their faith and confidence in you has not been misplaced.

If you need additional training in regard to advanced perio instrumentation, so be it. But, always put your best foot forward. Be confident in your abilities and your patients will be confident too.

10. Maintenance and follow-up — One of the most overlooked components of care really is a direct result from the complacency issue. Nothing will make your patient feel more "used" than when tossed aside as a result of a lack of follow-up and maintenance.

There is no excuse for a patient to fall through the cracks of your practice. The only way this can even occur is if you let it happen by becoming so complacent, so routine, so involved in just providing the bare-bones six-month prophy that you simply forget. While you must stay on top of the current and ever-changing tides of our profession, you must follow the track of your patients who trust you enough to accept the treatment you recommended.

Know that providing adequate care is good, but superlative care is supreme. So get back to the basics, take pride in a commitment to excellence that is second to none, and say goodbye to clinical complacency forever.

Tammy L. Carullo, RDH, PC, PS, is CEO of Practice by Design, Inc. She is a practice-management consultant and continuing-education instructor. She may be contacted by e-mail at [email protected]or phone (717) 867-5325. For more information about her company, visit her Web site at